BACKGROUND: A small subset of Indian people living/diagnosed with cancer commits suicide. The prevalence and changing trends in such cancer-related suicides are not much reported in literature. An attempt is made to address this subset of suicides during 2001–2014. MATERIALS AND METHODS: Data for this study were collected from the Indian National Crime Bureau Record, cancer registry publication in open domain, and published literature. Trends in the number of suicides associated with state, age groups, genders, and years were the only available parameters. Using these data, descriptive statistics of the rate of suicides, linear trend with age groups, gender, and geographical divisions are presented. RESULTS: During the study period of 14 years, 1,721,946 suicides with an average of 122,996 suicides per year were observed. One in five suicides was related to illness. In total, a sum of 10,421 cancer-related suicides were noted accounting a mean of 744 suicides per year. Males were commonly involved than females. The commonly involved age group was 45–59 years. Southern parts of India had more instances of cancer-related suicides. Among Indian states, West Bengal reported the highest of such instances. DISCUSSION: Suicide trends among Indians living with cancer during 2001–2014 are presented. The possible causes behind this phenomenon and implications are presented. The effect of changes in the trends in terms of geographical distribution, age group distribution, and gender dynamics is presented and discussed in this context. CONCLUSION: Suicide among PLWC is a multi-dimensional, complex phenomenon, orchestrated by several factors, including mental health. The nascent field of psycho-oncology in India needs to explore this through large scale validated studies.

Suicide rates of a country often are an indirect reflection of cultural ethos pertinent to suicide.[1] In India, suicide, as a form of death, is severely condemned, forbidden, and not encouraged except in extraordinary situations. Over the years and generations, Indian system has evolved cultural norms and practices such as deep family attachments and bonds, commitments, and social stigma against suicide. This has been quite successful in keeping suicides at low rates for centuries. With education, changing social structures and mass media exposure, all these factors happening in a short period has led to an increase in the rate of suicide among Indians.[1] In the past decade, the annual crude incidence of completed suicide in India is reported to vary in the range of 10–11.4 per 100,000 general population.[2],[3],[4]

Internationally, several population-based, registries-based, and census-based studies have identified the higher prevalence of suicide among the people living with cancer (PLWC).[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] Such reports emanate from Nordic countries in the last part of 20th century [5],[6],[7],[8],[9],[10] such as Switzerland,[11] Italy,[12],[13] England,[14] Estonia,[15] the USA,[16] Australia,[17] South Korea,[18] and Lithuania.[19] In most of these countries, an increased risk is definitive among PLWC males but differ among PLWC females.[16],[17] The risk of suicide is higher within the few weeks of initial diagnosis of cancer which then slowly decreases.[8],[9],[10],[11],[12],[13],[14],[15],[19] The elevated risk of suicide among PLWC remains even after 10 years of diagnosis.[20] The highest risk of suicide is often associated with respiratory and gastrointestinal cancers. Moderate risk exists with cancers of brain, nervous system, lymphatic, hematopoietic, and genital-related tumors.[19] Often, the suicide risk is elevated with cancers that are not localized and aggressive.[20],[21] In such studies, the suicide rate is shown to be dependent on gender, age, time since diagnosis, cancer site besides other demographical factors (such as economy, education levels, geographical location, and social status), and biological factors (pain, histological grading and type of tumor, organ system involved, metastasis, etc.). The rate is also influenced by sociocultural characteristics toward cancer patients and toward the suicide as well general rates of suicide in the population.[19] In addition, it must be borne in mind that the data used for the above-mentioned studies are at least a decade-old, and very few studies have been conducted in the recent past.[21]

In a study among Indian PLWC (n = 54), it has been reported that suicidal ideation was in the range of 20% (n = 11) and half (n = 5) of them harbored severe suicidal ideation, as reported by the Suicide Ideation Scale.[1] There are only a very few epidemiological studies of completed suicides among PLWC or suicide idealization from India.[1] The aim of this study was to present the brief epidemiology of completed suicides in relation to PLWC in India during the period of 2001–2014. In addition, an attempt is made to see this under the demographics feature of age group, gender, and overall illness-related suicide rates.

» Materials And Methods

The present data for this study were collected from the Indian National Crime Bureau records (NCBRs) (http://ncrb.nic.in). The reliability of these data had been previously questioned citing underreporting of the cases owing to several reasons, which is beyond the scope of this publication.[2],[3],[4] As these data have been the object of several accepted publications, they were used for the present study.[2],[3],[4] From the archives of the NCBR, all the suicide cases between 2001–2014 were collected and collated. From this, only data pertaining to suicides that were listed as those were identified with cancer, any illness, and total number of suicide were isolated and studied further. The year of suicide, age groups (classified as below 14 years, 15–29, 30–44, 45–59, and above 59 years), and gender (male/female) were collected. From the similar data source, the midyear population of the country, as reported by the Census Authority of India was collected. Depending on geographical positioning, for ease of computation, India was geographically categorized as:

North India (comprising the Indian territories of New Delhi, Chandigarh, Haryana, Himachal Pradesh, Jammu and Kashmir, Punjab, and Rajasthan)

East India (comprising the Indian territories of Bihar, Jharkhand, Uttarakhand, and Uttar Pradesh)

West India (comprising the Indian territories of Goa, Gujarat, Maharashtra, Dadar and Nagar Haveli, and Daman)

North-East India (comprising the Indian territories of West Bengal, Sikkim, Assam, Arunachal Pradesh, Meghalaya, Nagaland, Manipur, Mizoram, and Tripura. Note: Cause of suicides in West Bengal in the year 2012 was not listed and hence, it appears missing)

Central India (comprising the Indian territories of Madhya Pradesh, Chhattisgarh, and Odisha).

Rate of suicide and rate of illness related to suicide among general population were derived using the below-mentioned formulas:

For the period of 2001, the number of PLWC was deduced from a previously published study.[22] The number of new cancer cases diagnosed yearly was deciphered from various population-based predictions and Indian Council of Medical Research-based registry publications.[23],[24],[25]

Mortality among PLWC population of the years 2001 and 2012 was deduced from the WHO database.[26] An average rate of this value was used for this study. The mortality among the general population was derived from the World Bank indicators.[27] Using these values, the approximate number of death due to cancer was derived.-

The number of PLWC was calculated using the formula:

Number of PLWC (in year X) = Number of PWLC in year (X − 1) + New cancer cases diagnosed in year X − People who died due to cancer in year (X − 1).

The rate of suicide among PLWC was calculated by using the following formula:

This was later converted to per lakh population by multiplying by 100,000. From the raw data, graphs were plotted for males and females separately to identify the influence of changes with year among various age groups. The data did not permit the individual details of each incidence of suicide. Only collective numbers were given, as no statistical deduction is possible, only descriptive statistics is presented.

» Results

In the 14 years of the study period, a total of 10,421 completed suicides were related to cancer in a total of 1,721,946 patients. This accounts for 0.61% of all suicides over a period of 14 years. Of the 10,421 suicides, 7157 were males and the rest were females. Among the males and females, the most common age group to be involved was 45–59 years of age (n = 2768 and n = 1994, respectively) followed by 30–44 years (n = 1224 and n = 983, respectively). [Table 1] shows the factors that were computed to estimate the rate of suicide in general population, suicides rate related to all illness, and rate of suicide among PWLC. [Graph 1] shows the annual trends of these parameters in a diagram on both axes. [Graph 2] shows that the rate of suicide is inversely proportional to the rate of suicide among PWLC from 2001 to 2013, after which the trend appears to correlate.

Table 1: Incidence and rate of suicide, total illness-related suicide, and cancer-related suicide

In terms of age group, [Graph 3]a shows the annual changes in the age group distribution among males whereas [Graph 3]b shows the same among females. In both genders, the 45–59 years are more commonly involved followed by the 30–44 years in males and the above 60-year age groups in females. The least cancer-related suicides occurred in patients below the age of 14 years. It is also seen that among males, since 2012, the rate of occurrence is dipping while among females, the rate of occurrence across all age groups appears to be narrowing down to a short range.

[Table 2] shows the age wise distribution among various regions of India. The cancer-related suicide is more common in Southern states (n = 4345) followed by North-East India (n = 2448), West India (n = 2087), and the lowest incidence occurred in North India (n = 360) over the study period. It shall be noted that West Bengal had no causes listed for the year 2012. [Table 3] shows the top five states and lowest five states that account for suicides among PWLC. West Bengal, with 1967 suicides (even without including the statistics for the year 2012), emerged as a single largest state contributing to the 10,421 suicide, about 19% of all suicides. This is closely followed by Kerala (n = 1479), Andhra Pradesh (1431), and Maharashtra (n = 1429).

“For it is not death or pain that is to be feared, but the fear of pain or death”[28] is the comment about death by early Greek Stoic Philosopher Epictetus (55–135 AD). Adding to this, it is the death that is not painful, but the mere waiting for death is more painful. The waiting for known, painful, eminent, and impending death is a constant threat to the well-being of an individual. The news of cancer is often broken to the Indian patient by the attending physician/surgeon, often without pre- and post-test professional counseling. On hearing this information, the patient usually transgresses several psychological constructs such as denial, anger, bargaining, depression, and finally acceptance. The length and existence of each construct is dependent on the psychological make-up of an individual, his/her immediate surroundings and his/her notion of death. Pre-existing psychiatric conditions and substance abuse may worsen the condition. The suicidal ideation may be further reinforced due to financial conditions, fear of pain/treatment, and a host of other socio-moral-financial obligations.

In the recent autobiography on his fight against end-stage lung cancer, a neurosurgeon resident, Dr. Paul Kalanithi and a member of research team that discovered the phenomenon of optogenetics (new technique to study brain in living), describes his intense fight and outlook toward end-stage cancer. As a medical professional, well versed with mysteries surrounding cancer treatment, prognosis, statistics, and trials as well as a patient himself, he proceeds to give a rare glimpse how a human battles and waits for his/her end with a true sense of dignity.[29] But, not all humans are like Dr. Paul Kalanithi. Fleeting of ideas and suicidal ideation cannot be avoided, given the serious nature of disease and its portrayal.

The rate of suicide among Indian PWLC population was relatively higher as compared to general population during the study period [Graph 2]. The rates, as per our observation, were fluctuating. In 2001, the rate of suicide among PWLC was nearly thrice as those of the general population while it was nearly 1.4 times at the end of the study period. This trend was reported earlier with a phenomenon known as “Law of initial values” by earlier researchers among PLWC.[12],[15] As per this description, the effect of cancer on suicide is lower in populations with higher suicide rates. On comparing the results, with progressively increasing national level higher suicide rates [Graph 2] during the entire study period, we could observe the decreasing rate of suicide among PLWC. This could be explained in two ways as follows:

The increasing survival hopes among PLWC with better treatment options and facilities in the recent past strongly discourage suicidal idealization (cancer is becoming conquerable – decrease in the numerator)

The rapidly increasing number of PLWC is due to better quality of life, postdiagnosis, and treatment. The rate of suicide, being a function of surviving PLWC, is turned low, as this leads to an increase in the denominator in calculation. This can be compared with the numbers shown in [Table 1].

In addition, this trend as described earlier in certain countries proved to be false in 2013 and 2014, wherein the trend began to coincide.[15] Probably, this relates more to the statistical saturation rather than an actual phenomenon. More attention in this regards needs to be paid in future studies. Interestingly, PWLC living in the Indian state of West Bengal (North Eastern Region) had the highest number of suicides. This probably relates to the fact that better treatment facilities to cancer are available for PLWC in West Bengal rather than their home states in North Eastern Region. As the rate of cancer is much higher in North Eastern states,[23] most of the PLWC would have relocated to West Bengal for their treatment leading to registering of their suicide with West Bengal authorities rather than their home state. The support for this hypothesis comes from the fact that other North Eastern states have few or no incidence of suicide [Table 2] and [Table 3], though they have a high incidence of cancer and thus more PLWC. Creation of newer regional cancer centers in North Eastern states is a recent phenomenon, and outcomes would take a longer time to percolate to all PLWC beneficiaries.[23] The strong negative factor to the “Law of initial values” comes again in the form of the states of Kerala and Karnataka where the rate of suicides has traditionally remained high than the national average data (www.ncrb.nic.in). Probably, the correlation lies with numerous other confounders such as pre-existing substance abuse and psychiatric illness – both which are again much are common in these states.[2],[3],[4] In addition, the geographical proximity of the top five states to the coastal region needs to be accounted. There are reports to support that inherently, the rates of suicides are higher among the coastal region rather than the inland regions of the country.[30]

As we lacked access to more detailed, individual data, detailed analysis and subsequent comparison to the published literature were not possible. An adequate access to (i) basic demographics (ii) and the type and site of cancer been available would have facilitated a much more detailed analysis. Till such a detailed data are available, the estimates and risk factors of suicide among PLWC could not be easily identified. More correlative details such as those available for previously published studies would have given us more insight into this phenomenon.[15],[22]

As per the available literature, males have a higher incidence of suicides than females, though the Indian females carry a slightly higher incidence of cancer. In spite of this, the low incidence of suicide among females indicates that gender disparity exists in suicide idealization and completion among PLWC.[31] The age group commonly involved is 45–59 years of age closely followed by 30–44 years of age. Together, they constitute about 45% of the involved cases. Our present study is in agreement with the similar trend in a population-based mortality study among Indian PLWC.[22] With this age group being more prone to cancer, the number of people year lost due to suicide would drastically increase. The suicide idealization at this age may be related to the cancer-related financial instability, concern about the economic and other integral aspects of dependents including children education, marriage prospects, spouse life, disfigurement due to cancer, stigma attached to cancer, potential loss of income due to morbidity/mortality, etc.

Furthermore, the relatively higher incidence of cancer among PLWC indicates the necessity of proper psychiatrical counseling and attention that PLWC requires. This association needs to be initiated in the pretest or during diagnosis process itself. This would help to reduce the suicide idealization and completion. The present observation of increased suicides among PLWC poses two questions – whether the psychological impact of a diagnosis of cancer predisposes one to suicide or the disease process by itself promotes suicidal tendency. The increased prevalence of mental health illness such as anxiety and depression among PLWC supports the previous notion [1],[20],[21] while an interesting observation of a forensic autopsy data carried out in suicide and control cases (n = 232) attempts to support the latter notion. In this study, cancer was identified in 8.6% of the suicide cases as against the 3.9% in controls with significance (P = 0.03). The presence of cancer was not known to the deceased in 70% of the cases. Depression was associated in 75% of the cancer-related suicide cases (n = 20).[32] As the sample size was small to decipher cause association with a high degree of association, the result of this study needs to be interpreted with caution. However, their results indicate that the presence of malignant tumor, irrespective of their diagnosis, may predispose an individual to suicide, the mechanism of which is still largely unknown.

The study indicates that the prevalence of suicides among Indian PLWC is higher than the general population. Given the higher risk, more research needs to be focused in this arena. The higher risk of suicides in PLWC as reported recently in several other chronic diseases needs to be viewed with concern.[33] In addition, the possibility of misreporting of such instances of PLWC suicides as intentional or accidental accidents, poisoning, etc., needs to be factored in future studies.[33]

The major limitation of this study is that most of the data are indirect and no direct data were available. The reliability and accuracy of the data can be questioned as most of them are projected ones rather than actual ones that have been collected on fields. Till such data are available, the numbers observed in this study can be used by Indian policy framers to construct oncological and psychiatric-related policies with regard to suicides. The study further underlines the need for a mental health professional in oncological team to diagnose even, mild or subclinical forms/signs/symptoms of depression, anxiety, failing or poor social support systems, and demoralization (manifesting as hopelessness, distress, aloneness, and yearning). Rigorous screening for such psychiatric conditions would not only prevent suicidal thoughts or actions but also would serve to increase the adherence of cancer treatment. Focus of these professionals shall be primarily on existential issues and secondarily on attenuating pessimistic thoughts.

» Conclusion

The present study, for the first time, presents data on the prevalence of suicide among Indian PLWC. These data will highlight the need for inclusion of mental health workforce in cancer team not only to reduce substance abuse or treat signs/symptoms of mental illness but also to reduce pessimistic or suicidal thoughts and to impart positive feelings and rekindle hope in this highly vulnerable population.